ANAESTHESIA DR. SHAH SUDHIRCHANDRA M.D., D.A.(ANAESTHESIA)

ANAESTHESIA 1. General Anaesthesia (G.A.) 2. Regional Anaesthesia (R.A.)

GENERAL ANAESTHESIA Reversible loss of consciousness accompanied by analgesia, hypnosis and loss of reflexes with or without muscle relaxation 1. Spontaneous breathing 2. Controlled ventilation

REGIONAL ANAESTHESIA Only a part of the body is anaesthetised Types 1. Central blocks 2. Peripheral blocks

CENTRAL BLOCK 1. Spinal Analgesia 2. Epidural Analgesia 3. Caudal Analgesia

ANATOMY VERTEBRAL COLUMN Spinal cord is protected by vertebral column 33 vertebrae 4 spinal curves Cervical7 Thoracic12 Lumber5 Sacral5 Coccygeal4 Total33

ANATOMY SPINAL CORD Spinal cord is covered by 3 membranes 1. Pia 2. Arachnoid 3. Dura

PERIPHERAL BLOCKS 1. Surface anaesthsia – EMLA cream 2. Infiltration block – subcut. tissue 3. Nerve blocks 4. Field block - Inguinal field block

NERVE BLOCKS 1. Upper extremity blocks A Supraclavicular block B Axillary block C Elbow block D Wrist block E Digital block

NERVE BLOCKS 2. Lower extremity blocks A. Sciatic nerve block B. Femoral nerve block C. Popliteal block D. Ankle block E. Digital nerve block

NERVE BLOCKS 3. Peribulbar block – eye operations Cataract surgery 4. Penile block – circumcision 5. Dental block – tooth extraction

PREOPERATIVE CHECKUP History Previous operation Diseases Hypertension, diabetes, asthma and heart diseases Medications Allergy

PREOPERATIVE CHECKUP General examination Pulse, B/P, colour and temp. Systemic exam CVS and Resp. system exam. Investigations Hb, electrolytes, ECG and x ray chest American Society of Anaesthesiologist (ASA) grading of patient for risk of anaesthesia (1 to 6) Patient information about type of anaesthesia and its complications Consent

PREMEDICATION Premedication Pethidine 1 mg/kg I.M. Maxalon 0.2 mg/kg I.M. Syrup vellargan 3 mg/kg orally Ranitidine ( Zantac) 150 mg orally Diazepam 5 to 10 mg at night on previous day

General anaesthesia Cannulation 22 to 24 G cannula in children 20 to 18 G cannula for adult I/V fluids 5% D/S or hartman soln. Gelafusin soln. Blood

GENERAL ANAESTHESIA Preoxygenation for 3 min. Induction Fentanyl 1 mcg/kg Propofol 2 to 3 mg/kg Soya bean and egg phosphide solvent Intubation Tracrium 0.5 mg/kg muscle relaxant or Scoline 2 mg/kg for emergency cases as rapid onset of action

GENRAL ANAESTHSIA Intubation with endotracheal tube or L.M.A. inserted or holding face mask E.T tube Size 8 to 8.5 mm for men Size 7 to 7.5 mm for female Children Age/4 + 4 mm

INTUBATION

LARYNGEAL MASK L.M.A. size 4 for men L.M.A. size 3 for female L.M.A. size 1, 1.5, 2, 2.5 for children Insertion technique

Advantages of lma 1. Supraglottic device - no irritation of larynx 2. Easy to insert 3. Laryngoscope is not necessary – blind intubation 4. Awake insertion possible 5. Life saving for difficult intubation 6. E.T tube can be passed through LMA 7. Tolerated at lighter plane of anaesthesia

MAINTENANCE O2 (40%) + N2O (60%) + Isoflurane (1%) Spontaneous breathing or controlled ventilation Tracrium and Fentanyl are repeated every 30 min. Continuous monitoring

monitoring Continuous monitoring 1. Electrocardiogram (E.C.G.) 2. SPO2 Saturation of Hb – normal 97% 3. End tidal CO2 4. Blood pressure Systolic, diastolic and mean pressure every 5 min. 5. Temperature - warming matress

reversal Reversal of relaxant drug Tracrium at the end of operation N2O and Isoflurane are stopped Only O2 given to the patient Neostigmine 2.5 mg + atropine 1 mg Oral suction Extubation only when patient conscious and coughing O2 by face mask Monitoring of vital signs Shifted to recovery room when vital signs are stable

RECOVERY O2 by face mask Monitoring SPO2, B/P and ECG Warming blanket Treat any complications Nausea/ vomiting – maxalon or zofran Adequate pain relief I/V Fentanyl or I/M Pethidine Aldrete scoring system Shifted to ward when vital signs are stable

SPINAL ANALGESIA Local anaesthetics Lignocaine 1% 2 ml for L.A. at L2-3 interspace Marcaine (Bupivacaine) 0.5% 2to 2.5 ml with fentanyl 25 mcg Autonomic, sensory and motor nerve block upto T6-8 level Duration 3 to 4 hours

SPINAL ANALGESIA Spinal needle – 25 G pencil point needle Spinal cord 45 cm long 3 covering membranes Dura, arachnoid and pia membranes Cerebro spinal fluid (C.S.F.) is in subarachnoid space

Spinal analgesia Complications 1. Hypotension Fluids, ephedrine 6 mg 2. Shivering Warming blanket, Pethidine 25 mg, O2 3. Nausea, vomiting Maxalon, Zofran 4. Respiratory depression

Spinal analgesia 5. Headache – C.S.F. loss 6. Backache

Anatomy of epidural space

EPIDURAL ANALGESIA

18-16 G Touhy needle inserted into epidural space at any level depending on site or operation Catheter is inserted thro’ the needle upto 8 to 9 cm at skin level Needle is removed and catheter is fixed to the back of the patinet

Epidural- Catheter

EPIDURAL ANALGESIA Complications 1. Total spinal 2. Hypotension 3. Nausea and vomiting 4. Patchy analgesia 5. Headache 6. Epidural abcess 7. Backache

CAUDAL BLOCK 21 G needle is inserted into thro’ sacral haitus 15 TO 20 ml.25% marcaine injected Lower abdominal surgery Children for postop pain relief Herniotomy, circumcision

EMERGENCY DRUGS 1. Atropine Bradycardia pulse less than 50/min 2. Adrenaline Cardiac arrest, allergy 3. Ephedrine 6 to 9 mg low blood pressure 4. Labetolol 3 to 5 mg Low blood pressure

EMERGENCY DRUGS 5. Hydrallazine High blood pressure 6. Piriton 10 mg Allergy 7. Dopamine, dobutamine To increase blood pressure and cardiac output 8. Hydrocortisone Allergy

EMERGENCY DRUGS 9. Narcan To reverse overdose of narcotics 10. Maxalon 10 mg Nausea and vomiting 11. Zofran Nausea and vomiting

SUMMARY 1. General and regional anaesthesia 2. Selection of patient for anesthesia is very important 2. Monitoring and safe anesthesia are vital throughout anesthesia 4. Adequate recovery of patient before sending to ward

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